Copay Eligibility Questions

Universal API Implementation Guide - Local Development build (v1.1.20) built by the FHIR (HL7® FHIR® Standard) Build Tools. See the Directory of published versions

Qualifying for Copay Assistance
GET Questionnaire:
Questionnaires Common to All Products
Inserting Product, Brand, Program Phone Number in Questionnaire Text
Product Specific Questionnaires
Other Questionnaires
Questionnaire Responses

Qualifying for Copay Assistance

In order to determine if a patient qualifies for Copay assistance, patients must answer a set of eligibility questions. In addition, there are non-elgibility questions that may be asked. A question is represened by a 'Questionnnaire' and the response is known as a 'QuestionnaireResponse'. In the Enrollment Request bundle, the client system will provide a QuestionnaireResponse to each question.

GET Questionnaire:

Client system is responsible for selecting specific questionnaires which need to be included in the Enrollment bundle. Questionnaires can be retrieved by requesting Questionnaire definitions from the Genentech FHIR Server. Based on product and version number, Genentech will respond back with questionnaires that are specific for that product. details.

The Questionnaire endpoint should be queried with specific product and version.

GET {UAPI_Copay_URL}/v1/questionnaire?name=CoPay%20Cotellic

The ‘name’ parameter is the product name and is required.
The version number is the supported version of that questionnaire and is optional. If version number is not provided, then the response will be the latest version.

Questionnaires Common to All Products

The following questionnaires are standard across all products and are required for completing the patient's Copay enrollment, unless stated otherwise.

LinkId	Text	Expected Values
consent-to-enroll	"Does the patient consent to enroll in the [product name] Co-Pay Program?"	Yes or No
18-years-or-older	"Is the patient 18 years of age or older"?	Yes or No
(product)-fda-approved-indications	Is the patient using [product name] for one of the following FDA-approved indications?	refer to section 3.4.1 for details
commercial-private-insurance	"Is the patient on commercial (also known as private) insurance? This includes insurance from an employer and non-government funded insurance purchased from a health insurance marketplace".	Yes or No
federal-state-funded-insurance	"Is the patient using any federal or state-funded health care program? This includes, but is not limited to, Medicare, Medicaid, Medigap, VA, DoD and TRICARE."	Yes or No
have-medicare-card	Does the patient have a Medicare (red, white and blue) card?	Conditional, only add if QuestionnaireResponse to 'federal-state-funded-insurance' is 'Yes' Options: Yes or No
enter-medicare-number	Enter the Medicare Number	Conditional, only add if QuestionnaireResponse to 'have-medicare-card is 'Yes'
residence-state	What state does the patient live in?	2 character state abbreviation
receiving-medication-from-gpf	Is the patient currently receiving [product name] from the Genentech Patient Foundation?	Yes or No
receiving-assistance-from-charitable-organization	Is the patient currently receiving assistance from any other charitable organization for any of their out-of-pocket costs that are covered by the [product name] Co-pay Program?	Yes or No
agree-to-genentech-privacy-policy	The patient acknowledges and agrees that any patient information disclosed during enrollment, including contact information, demographic information, and sensitive personal information, such as information related to the patient's medical condition, treatments, and health insurance benefits, will be shared with Genentech, the sponsor of the program, its partners, and their respective affiliates. In addition, information shared by the pharmacy/physician, such as the date the prescription was filled, the date the medication was administered by the physician (if applicable) and the amount that will be reimbursed by Genentech will also be shared. The patient authorizes Genentech to receive, use, and share the patient's personal information in connection with the [Brand] Co-pay Program. The patient agrees to be contacted by phone, mail, or email about the [Brand] Co-pay Program. For more information, please see the Genentech Privacy Policy at www.gene.com/privacy-policy. To withdraw from the Program, please contact the Program at [Program phone number] Monday through Friday between 9am – 8pm ET.	Agree or Do Not Agree
agree-to-copay-program-terms	The Co-pay Program (“Program”) is valid ONLY for patients with commercial (private or non-governmental) insurance who have a valid prescription for a Food and Drug Administration (FDA)-approved indication of a Genentech medicine. The Program is not available to patients whose prescriptions are reimbursed under any federal state, or government-funded insurance programs (included but not limited to Medicare, Medicare Advantage, Medigap, Medicaid, TRICARE, Department of Defense, or Veterans Affairs Programs) or where prohibited by law or by the patient's health insurance provider. If at any time a patient begins receiving prescription drug coverage under any such federal, state or government-funded healthcare programs, the patient will no longer be eligible for the Program. The Program is not valid for Genentech medicines that are eligible to be reimbursed in their entirety by private insurance plans or other programs. Under the Program, the patient may be required to pay a co-pay. The final amount owed by a patient may be as little as $0 for the Genentech medicine (see Program specific details available on the Program Website). The total patient out-of-pocket cost is dependent on the patient’s health insurance plan. The Program assists with the cost of the Genentech medicine only. It does not assist with the cost of other medicines, procedures or office visit fees. After reaching the maximum annual Program benefit amount, the patient will be responsible for all remaining out-of-pocket expenses. The Program benefit amount cannot exceed the patient’s out-of-pocket expenses for the Genentech medicine. The maximum Program benefit will reset every January 1st. The Program is not health insurance or a benefit plan. The patient’s non-governmental insurance is the primary payer. The Program does not obligate the use of any specific medicine or provider. Patients receiving assistance from charitable free medicine programs (such as the Genentech Patient Foundation) or any other charitable organizations for the same expenses covered by the Program are not eligible. The Program benefit cannot be combined with any other rebate, free trial or other offer for the Genentech medicine. No party may seek reimbursement for all or any part of the benefit received through the Program. The Program may be accepted by participating pharmacies, physicians’ offices or hospitals. Once a patient is enrolled, the Program will honor claims with a date of service that precedes the Program enrollment date up to 180 days. Claims must be submitted within 365 days from the date of service unless otherwise indicated. Use of the Program must be consistent with all relevant health insurance requirements. Participating patients, pharmacies, physicians’ offices and hospitals are responsible for reporting the receipt of all Program benefits as required by any insurer or by law. Programs’ benefits may not be sold, purchased, traded or offered for sale. The patient or their guardian must be 18 years of age or older to receive Program assistance. The Program is only valid in the United States and U.S. Territories, is void where prohibited by law and shall follow state restrictions in relation to AB-rated generic equivalents (e.g., MA, CA) where applicable. Eligible patients will be automatically re-enrolled in the Program on an annual basis each January 1st. Eligible patients will be removed from the Program after 3 years of inactivity (e.g., no claims submitted in a 3-year timeframe). Patients who choose reimbursement via virtual debit card will have access to the patient’s funds as long as the patient's virtual debit card is valid and the patient is active in the Program. Once a patient's virtual debit card has expired and they are no longer active in the program, the funds will be removed from the virtual debit card. Program eligibility and automatic re-enrollment are contingent upon the patient’s ability to meet all requirements set forth by the Program. Healthcare providers may not advertise or otherwise use the Program as a means of promoting their services or Genentech medicines to patients. The value of the Program is intended exclusively for the benefit of the patient. The funds made available through the Program may only be used to reduce the out-of-pocket costs for the patient enrolled in the Program. The Program is not intended for the benefit of third parties, including without limitation third party payers, pharmacy benefit managers, or their agents. If Genentech determines that a third party has implemented a program that adjusts patient cost-sharing obligations based on the availability of support under the Program and/or excludes the assistance provided under the Program from counting towards the patient’s deductible or out-of-pocket cost limitations, Genentech may impose a per fill cap on the cost- sharing assistance available under the Program. Submission of true and accurate information is a requirement for eligibility and Genentech reserves the right to disqualify patients who do not comply with Genentech Program Terms and Conditions. Genentech reserves the right to rescind, revoke or amend the Program without notice at any time.	Agree or Do Not Agree
agree-to-admin-copay-program-terms	The Administration Co-pay Program (“Program”) is valid ONLY for patients with commercial (private or non- governmental) insurance who have a valid prescription for a Food and Drug Administration (FDA)-approved indication of a Genentech medicine. The Program is not available to patients whose prescriptions are reimbursed under any federal state, or government-funded insurance programs (included but not limited to Medicare, Medicare Advantage, Medigap, Medicaid, TRICARE, Department of Defense, or Veterans Affairs Programs) or where prohibited by law or by the patient's health insurance provider. If at any time a patient begins receiving prescription drug coverage under any such federal, state or government-funded healthcare programs, the patient will no longer be eligible for the Program. The Program is not valid for administration that is eligible to be reimbursed in their entirety by private insurance plans or other programs. If the patient chooses to enroll in the Drug Co-pay Program, the patient must separately enroll and meet all eligibility criteria of that program. Under the Program, the patient may be required to pay a co-pay. The final amount owed by a patient may be as little as $0 for the administration of the Genentech medicine (see Program specific details available at the Program Website). The total patient out-of-pocket cost is dependent on the patient’s health insurance plan. The Program assists with the costs of the administration of the Genentech medicine only. It does not assist with the cost of other administrations, medicines, procedures or office visit fees. After reaching the maximum per treatment or annual Program benefit amounts, the patient will be responsible for all remaining out-of-pocket expenses. The Program benefit amount cannot exceed the patient’s out-of-pocket expenses for the administration fees for the Genentech medicine. The maximum Program benefit will reset every January 1st. The Program is not health insurance or a benefit plan. The patient’s non-governmental insurance is the primary payer. The Program does not obligate the use of any specific medicine or provider. The Program is valid for patients receiving free medicine from the Genentech Patient Foundation. The Program is not valid for patients receiving assistance from any other charitable organizations for the same expenses covered by the Program. The Program benefit cannot be combined with any other rebate, free trial or other offer for the administration of the Genentech medicine. No party may seek reimbursement for all or any part of the benefit received through the Program. The Program may be accepted by participating pharmacies, physicians’ offices or hospitals. Once a patient is enrolled, the Program will honor administration claims with a date of service that precedes the Program enrollment up to 180 days. Claims must be submitted within 365 days from the date of service unless otherwise indicated. Use of the Program must be consistent with all relevant health insurance requirements. Participating patients, pharmacies, physicians’ offices and hospitals are responsible for reporting the receipt of all Program benefits as required by any insurer or by law. Programs’ benefits may not be sold, purchased, traded or offered for sale. The patient or their guardian must be 18 years of age or older to receive Program assistance. The Program is only valid in the United States and U.S. Territories and is void where prohibited by law. The Program is not valid for patients who reside or receive treatment in a restricted state (e.g. Massachusetts or Rhode Island). Eligible patients will be automatically re-enrolled in the Program on an annual basis. Eligible patients will be removed from the Program after 3 years of inactivity (e.g., no claims submitted in a 3-year timeframe). Patients who choose reimbursement via virtual debit card will have access to the patient’s funds as long as the patient's virtual debit card is valid and the patients are active in the Program. Once a patient’s virtual debit card has expired and they are no longer active in the program, the funds will be removed from the card. Program eligibility and automatic re-enrollment are contingent upon the patient’s ability to meet all requirements set forth by the Program. Healthcare providers may not advertise or otherwise use the Program as a means of promoting their services or Genentech medicines to patients. The value of the Program is intended exclusively for the benefit of the patient. The funds made available through the Program may only be used to reduce the out-of-pocket costs for the patient enrolled in the Program. The Program is not intended for the benefit of third parties, including without limitation third party payers, pharmacy benefit managers, or their agents. If Genentech determines that a third party has implemented a program that adjusts patient cost-sharing obligations based on the availability of support under the Program and/or excludes the assistance provided under the Program from counting towards the patient’s deductible or out-of-pocket cost limitations, Genentech may impose a per fill cap on the cost- sharing assistance available under the Program. Submission of true and accurate information is a requirement for eligibility and Genentech reserves the right to disqualify patients who do not comply with Genentech Program Terms and Conditions. Genentech reserves the right to rescind, revoke or amend the Program without notice at any time.	Conditional, only add if product has a Copay Admin program Options: Agree or Do Not Agree
information-correct	All information is correct	Yes or No

Inserting Product, Brand, Program Phone Number in Questionnaire Text

The following Copay questionnaires require the product, brand name and/or phone in the questionnaire text (refer to text column in table above). This assumes that questionnaire text field (optional) is included in bundle:

consent-to-enroll
(product)-fda-approved-indications
receiving-medication-from-gpf
receiving-assistance-from-charitable-organization
agree-to-genentech-privacy-policy

Product(s)	Brand	Phone Number
Esbriet	Esbriet	(877) 780-4958
ENSPRYNG	ENSPRYNG	(800) 636-0373
Evrysdi	Evrysdi	(800) 636-0316
HEMLIBRA	HEMLIBRA	(844) 436-2672
OCREVUS OCREVUS ZUNOVO	OCREVUS	(844) 672-6729
PiaSky	PiaSky	(800) 888-8051
Pulmozyme	Pulmozyme	(877) 794-8723
XOLAIR	XOLAIR	(855) 965-2472
Actemra Intravenous Actemra Subcutaneous	ACTEMRA	(855) 722-6729
Rituxan for Immunology	Rituxan for Immunology	(855) 722-6729
Alecensa, Avastin, Columvi, Cotellic, Erivedge, Gazyva, Herceptin, Herceptin Hylecta, Kadcyla, Lunsumio, Perjeta, Phesgo, Polivy, Rituxan Hycela, Rituxan for Oncology, Rozlytrek, Tecentriq, Tecentriq Hybreza, Venclexta, Zelboraf	Genentech Oncology	(855) 692-6729
Lucentis Susvimo Vabysmo	Genentech Ophthalmology	(855) 218-5307

Example: If linkId text for "agree-to-genentech-privacy-policy" is included in Copay Vabysmo request bundle:

{
"linkId": "agree-to-genentech-privacy-policy",
"text": "...the **[Brand]** Co-pay Program...about the **[Brand]** Co-pay Program...the Program at **[Program phone number]** Monday through Friday between 9am – 8pm ET.",
},

then from table above, Ophthalmology brand and phone# would be inserted into text field:

{
"text": "...the Ophthalmology Co-pay Program...about the Ophthalmology Co-pay Program...the Program at (855) 218-5307 Monday through Friday between 9am – 8pm ET.",

Product Specific Questionnaires

Some questions are applicable only when a specific product is selected. To identify these questions, custom “metadata” questions are introduced in each Questionnaire definition.

FDA-approved Indication Questionnaires

The eligibility question "Is the patient using [product for one of the following FDA-approved indications?" is required for all products.
The linkId is represented by the name of the product + '-fda-approved-indications'.

Example: Cotellic questionnaire for FDA indication:

{
  "linkId": "cotellic-fda-approved-indications",
  "text": "Is the patient using COTELLIC® (cobimetinib) for one of the following FDA-approved indications?",
  "type": "choice",
  "required": true,
  "answerOption": [
    {
      "valueCoding": {
        "code": "melanoma",
        "display": "COTELLIC is a prescription medicine that is used with the medicines ZELBORAF® (vemurafenib) and may be used with the medicine TECENTRIQ® (atezolizumab) or TECENTRIQ HYBREZA™ (atezolizumab and hyaluronidase-tqjs) to treat a type of skin cancer called melanoma that has spread to other parts of the body or cannot be removed by surgery, and that has a certain type of abnormal "BRAF" gene."
      }
    },
    {
      "valueCoding": {
        "code": "histiocytic-neoplasms",
        "display": "COTELLIC is a prescription medicine that is used as a single agent for the treatment of adult patients with histiocytic neoplasms.\n\nYour healthcare provider will perform a test to make sure that COTELLIC is right for you.\n\nIt is not known if COTELLIC is safe and effective in children under 18 years of age."
      }
    },
    {
      "valueCoding": {
        "code": "unsure",
        "display": "Unsure - Please contact physician's office for information"
      }
    },
    {
      "valueCoding": {
        "code": "none-of-the-above",
        "display": "None of the above"
      }
    }
  ]
},

Combo Therapy Questionnaires

In some cases, a patient may be able to select a combination of products (combo therapy). Actual combo therapy-related questions which need to be answered have “required” property set to true and its dependency on the response of a previous question is defined using “enabledWhen” property with reference to specific metadata question.

Example: Cotellic questionnaires for combo therapy with Zelboraf and Tecentriq:

This linkId should be included in enrollment request bundle if Cotellic FDA indication is 'melanoma'; the response to the question below can be either yes or no.

{
  "linkId": "cotellic-receive-copay-for-zelboraf",
  "text": "Does the patient wish to receive co-pay benefits for ZELBORAF as well?",
  "type": "choice",
  "enableWhen": [
    {
      "question": "cotellic-fda-approved-indications ",
      "operator": "=",
      "answerString": "melanoma"
    }
  ],
  "enableBehavior": "all",
  "required": true,
  "answerOption": [
    {
      "valueString": "Yes"
    },
    {
      "valueString": "No"
    }
  ]
},

This linkId should be included in enrollment request bundle if response to "linkId": "cotellic-receive-copay-for-zelboraf" is either yes or no; the response to the question below can be either yes or no.

{
  "linkId": "cotellic-combo-with-tecentriq",
  "text": "Is the patient also taking TECENTRIQ® (atezolizumab)?",
  "type": "choice",
  "enableWhen": [
    {
      "question": "cotellic-receive-copay-for-zelboraf ",
      "operator": "=",
      "answerString": "Yes"
    },
    {
      "question": " cotellic-receive-copay-for-zelboraf ",
      "operator": "=",
      "answerString": "No"
    }
  ],
  "enableBehavior": "any",
  "required": true,
  "answerOption": [
    {
      "valueString": "Yes"
    },
    {
      "valueString": "No"
    }
  ]
},

This linkId should be included in enrollment request bundle if response to "linkId": "cotellic-combo-with-tecentriq is yes; the response to the question below can be either yes or no.

{
  "linkId": "cotellic-receive-copay-for-tecentriq",
  "text": "Does the patient wish to receive co-pay benefits for TECENTRIQ or TECENTRIQ HYBREZA as well?",
  "type": "choice",
  "enableWhen": [
    {
      "question": "cotellic-combo-with-tecentriq ",
      "operator": "=",
      "answerString": "Yes"
    }
  ],
  "enableBehavior": "all",
  "required": true,
  "answerOption": [
    {
      "valueString": "Yes"
    },
    {
      "valueString": "No"
    }
  ]
},

Questionnaire Responses

In the Enrollment Request bundle, the client system will provide a QuestionnaireResponse to each question.

Responding to the Questionnaire examples in above section, the corresponding QuestionnaireResponses will be formatted as follows:

Example: QuestionnaireResponse to Consent

{
  "linkId": "consent-to-enroll",
  "text": "Does the patient consent to enroll in the [product name] Co-Pay Program?",
  "answer": [
    {
      "valueString": "Yes"
    }
  ]
},

Example: QuestionnaireResponse to Cotellic FDA Indication

"linkId": "cotellic-fda-approved-indications",
"text": "Is the patient using COTELLIC® (cobimetinib) for one of the following FDA-approved indications?",
"answer": [
  {
    "valueCoding": {
      "code": "melanoma",
      "display": "COTELLIC is a prescription medicine that is used with the medicines ZELBORAF® (vemurafenib) and may be used with the medicine TECENTRIQ® (atezolizumab) or TECENTRIQ HYBREZA™ (atezolizumab and hyaluronidase-tqjs) to treat a type of skin cancer called melanoma that has spread to other parts of the body or cannot be removed by surgery, and that has a certain type of abnormal "BRAF" gene."
    }
  }
]
},

Example: QuestionnaireResponse to Cotellic combo therapy with Tecentriq and Zelboraf

"linkId": "cotellic-receive-copay-for-zelboraf",
"text": "Does the patient wish to receive co-pay benefits for ZELBORAF as well?",
"answer": [
  {
    "valueString": "Yes"
  }
]
},
{
"linkId": "cotellic-combo-with-tecentriq",
"text": "Is the patient also taking TECENTRIQ or TECENTRIQ HYBREZA?",
"answer": [
  {
    "valueString": "Yes"
  }
]
},
{
  "linkId": "cotellic-receive-copay-for-tecentriq",
  "text": "Does the patient wish to receive co-pay benefits for TECENTRIQ or TECENTRIQ HYBREZA as well?",
  "answer": [
    {
      "valueString": "Yes"
    }
  ]
},

Example: QuestionnaireResponse to Administration Copay questionnaire

{
  "linkId": "agree-to-admin-copay-program-terms",
  "text": "The Administration Co-pay Program is valid ONLY for patients with commercial (private or non-governmental) insurance who have a valid prescription for a Food and Drug Administration (FDA)-approved indication of a Genentech medicine. Patients using Medicare, Medicaid, Medigap, Veterans Affairs (VA), Department of Defense (DoD), TRICARE or any other federal or state government program (collectively, “Government Programs”) to pay for their Genentech medicine and/or administration services are not eligible. The Program is not valid for administration that is eligible to be reimbursed in their entirety by private insurance plans or other programs. If the patient chooses to enroll in the Drug Co-pay Program, the patient must separately enroll and meet all eligibility criteria of that program.\n \n Under the Program, the patient may pay a co-pay. The final amount owed by a patient may be as little as $0 for the administration of the Genentech medicine (see Program specific details). The total patient out-of-pocket cost is dependent on the patient’s health insurance plan. The Program assists with the costs of the administration of the Genentech medicine only. It does not assist with the cost of other administrations, medicines, procedures or office visit fees. After reaching the maximum per treatment or annual Program benefit amounts, the patient will be responsible for all remaining out-of-pocket expenses. The Program benefit amount cannot exceed the patient’s out-of-pocket expenses for the administration fees associated with the Genentech medicine. The maximum Program benefit will reset every January 1st. The Program is not health insurance or a benefit plan. The patient’s non-governmental insurance is the primary payer. The Program does not obligate the use of any specific medicine or provider. The Program is valid for patients receiving free medicine from the Genentech Patient Foundation. The Program is not valid for patients receiving assistance from any other charitable organizations for the same expenses covered by the Program. The Program benefit cannot be combined with any other rebate, free trial or a similar offer for the administration of the Genentech medicine. No party may seek reimbursement for all or any part of the benefit received through the Program.\n \n The Program may be accepted by participating pharmacies, physicians’ offices or hospitals. Once a patient is enrolled, the Program will honor administration claims with a date of service that precedes the Program enrollment up to 180 days. Claims must be submitted within 365 days from the date of service unless otherwise indicated. Use of the Program must be consistent with all relevant health insurance requirements. Participating patients, pharmacies, physicians’ offices and hospitals are responsible for reporting the receipt of all Program benefits as required by any insurer or by law. Programs’ benefits may not be sold, purchased, traded or offered for sale.\n \n The patient or their guardian must be 18 years of age or older to receive Program assistance. The Program is only valid in the United States and U.S. Territories and is void where prohibited by law. The Program is not valid for Massachusetts or Rhode Island residents. Eligible patients will be automatically re-enrolled in the Program on an annual basis. Eligible patients will be removed from the Program after 3 years of inactivity (e.g., no claims submitted in a 3-year timeframe). Program eligibility and automatic re-enrollment are contingent upon the patient’s ability to meet all requirements set forth by the Program. Healthcare providers may not advertise or otherwise use the Program as a means of promoting their services or Genentech medicines to patients. The Program is intended for the patient. Only the patient using the Program may receive the funds made available through the Program. The Program is not intended for third parties who reduce the amount available to the patient or take a portion for their own purposes. Patients with health plans that redirect Genentech Program assistance intended for patient out-of-pocket costs may be subject to alternate Program benefit structures. Genentech reserves the right to rescind, revoke or amend the Program without notice at any time.",
  "answer": [
    {
      "valueString": "Agree"
    }
  ]
},

Example: QuestionnaireResponse to debit card questionnaire

{
  "linkId": "assign-debitcard",
  "text": "Do you require a 16-digit virtual card number to process the claim?",
  "answer": [
    {
      "valueString": "Yes"
    }
  ]
},